Effectiveness and Outcomes in Health Care Proceedings of an Invitational Conference (1990) / Chapter Skim
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21 Applying Effectiveness and Outcomes Research to Clinical Practice
21 Applying Effectiveness and Outcomes Research to Clinical Practice
Pages 179-189
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From page 179... ...
To meet its responsibility for ensuring the quality of care provided to Medicare beneficiaries, the Health Care Financing Administration launched a program within the Department of Health and Human Services. This Effectiveness Initiative will systematically gather information to improve our understanding of the relative effectiveness of alternative therapeutic approaches to conditions that commonly afflict Medicare beneficiaries (3~.
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From page 180... ...
Communication of such subjective value judgments involves a set of methodological issues that must be addressed if we are to preserve the responsiveness of health care to the wants and needs of individual patients. The third premise raises pragmatic issues about the possible integration of research and practice, not to mention epistemological questions.
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From page 181... ...
. The second alternative is less risky: the only possible outcomes are the most valued and an intermediate health state that happens to be the Q r 1 ~ Clinical ~L~ Decision Clinical A,/..///,'/ Outcome Practice FIGURE 1 A health outcome can be viewed as the product of a clinical process that begins with a decision or series of decisions about the interventionist most likely to meet a particular patient's health care needs and wants.
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From page 182... ...
Alternative 2, which looked so good without these numbers, now looks less promising: there is only a 10 percent Q l ,~ 1 ~ A ~1 Alternative ~ < Alternative 2 : FIGURE 2 An Abstract Representation of a Simple Clinical Decision. The crosshatched triangle superimposed on the patient represents the health state that has prompted medical care and the current decision.
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From page 183... ...
It can be said that knowledge is power because it confers the capacity to predict. Accurate estimation of outcome probabilities, as represented in these simple pie diagrams, captures the essence of professional knowledge related to the practice of medicine.
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From page 184... ...
The scientific requirements of research designed to determine the effectiveness of one intervention relative to another, which is nothing more than the relative outcome probabilities, include: similarity of the initial states; the integrity of the interventions; and similarity of detection or measurement of outcomes. Unfortunately, clinical research that meets these requirements is the exception rather than the rule.
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From page 186... ...
Whether the pie diagrams in Figure 3 represent probabilities of outcomes for a health care decision or a simple game of roulette, information about the likelihood of the outcomes must be accompanied by information about their relative values in order to be helpful to a decision maker. The top bar in Figure 5 represents a scale on which we can register the value judgments of the hypothetical patient with prostate disease.
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From page 187... ...
At this interface between outcomes research and clinical practice, the methodological issues relate more to the physicianpatient relationship and its effect on care and outcomes than to the scientific basis of medicine as defined by the biomedical model. New information about subjective responses to health states could also be of value to policymakers.
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From page 188... ...
_{'Profession~ ~ , Individual Clinical Decision Patients _, Values \ / Clinical A///////,// : Practice ~ V Aggregate \ Outcome FIGURE 6 A Model of Clinical Practice and Outcomes Research Functioning as a Feedback Loop. Aggregate outcomes of many individual clinical decisions serve as an information base that informs professional knowledge with outcome probabilities and simultaneously informs patients' and professionals' value judgments with previous patients' subjective responses to those outcomes.
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From page 189... ...
iEditors' Note: Now the Patient Outcomes Research Teams of the Agency for Health Care Policy and Research.
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